Faculty: Eric Zabirowicz, MD; Ursula Landman, DO
09-21-21 FACTT, NICESUGAR, PRORATA
Drs. Scorcese , Diamond , Kozlowski and Zabirowicz
6:00 PM @ Microsoft Teams
• NHLBI ARDS Clinical Trials Network. Comparison of Two Fluid-Management Strategies in Acute Lung Injury [N Engl J Med. 2006 Jun 15;354(24):2564-75]
• NICE-SUGAR Study Investigators. Intensive versus Conventional Glucose Control in Critically Ill Patients. [N Engl J Med. 2009 Mar 26;360(13):1283-97]
• Bouadma et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. [Lancet. 2010 Feb 6;375(9713):463-74.]
Dr. Kozlowski reviewed the Bouadma et al paper. It was really interesting to read and hear of the use of procalcitonin guided strategy to treat bacterial infections in non surgical patients in ICU and how it can reduce antibiotic exposure and selective pressure with no adverse outcomes . There were limitations - only 8 ICU s participated, surgical ICU patients represented only 10 percent of the population. Many Drs in the procalcitonin group did not follow the algorithm for d/c of antibiotics. 53% randomized the procalcitonin arm did not follow the algorithm treatment. A slightly higher number of patients in procalcitonin arm died between day 28 and 60. There was also no cost effectiveness analysis done. This study showed an interesting use of procalcitonin.
Dr. Scorcese summarized the article by Simon Finfer et al. This international randomized trial found that intensive glucose (BS) control increased mortality in ICU adult patients. During the discussion it was noted when to treat BS and how. It was also discussed that NYS requires a BS less than 200 before arrival to ICU after cardiac surgery. The 90 day mortality from the two groups was discussed and compared in this study and p value noted to be < 0.001.
Dr. Diamond gave a thorough review of Wiedemann et al. This study found no significant difference in primary outcome of 60 day mortality but conservative fluid management did improve lung function and shortened mechanical ventilation ICU care. During the discussion it was noted that the P value here was quite different compared to the NICE study. CVP pressure management was also discussed.
10-26-21 WAG. IOH. POH.
Drs. Mena, Parikh, Seiter
6:00 PM @ Microsoft Teams
• Varughese & Raza. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth Analg. 2021 Oct 1;133(4):826-835
• Gregory A, et al. Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery. Anesth Analg. 2021 Jun 1;132(6):1654-1665
• Khanna KA, et al. Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery. Anesth Analg. 2021 May 1;132(5):1410-1420
Dr Seiter gave an excellent concise review on the Gregory, et al paper. IOH during noncardiac surgery is associated with increased 30 day major adverse cardiac and cerebrovascular events. During the discussion it was noted that the study excluded all healthy individuals. The study found that young had more hypotension than older patients and clinically this is not seen. It would have been better to include all healthy young to have more useful conclusions.
Dr Mena gave a thorough review of the Varughese & Raza article. This narrative review of the impact of anesthetic waste noted that inhaled anesthetics contribute to greenhouse gas emissions although their contributions are lower than those of other human produced substances. It is important to recognize that there is a potential health risk to OR personnel if anesthetic gases not managed and scavenged well. During the discussion, mask induction in pediatric patients was discussed This leads to relatively higher exposure for those in pediatric practices. Unfortunately, this review did not discuss pediatric recommendations. It was really interesting to read and hear of the climate change greenhouse effects and threats to our reefs /coral & aquatic environments. Hopefully we can all help the environment by doing our part.
Dr Parikh summarized the Khanna, et al paper. This research found that POH in patients without IOH was not associated with MACCE (major adverse cardiac or cerebrovascular events) at any MAP. It was noted that large randomized trials are needed. During the discussion it was noted that there is bias here, too, due to the exclusion of sick patients. We compared this article to Gregory, et al. In both cases, the way in which the data was presented and analyzed can steer the reader to a point of view of the researchers.
02-15-22 Dr. Azim's NEMJ article! and a Buprenorphine study
Drs. Turkiew and Shafai
6:00 PM @ Curry Club at SaGhar, 111 W Broadway, Port Jefferson, NY 11777
• MD Neuman ... Azim S ... et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med. 2021 Nov 25;385(22):2025-2035
• Quaye et al. Perioperative Continuation of Buprenorphine at Low–Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation. Pain Med. 2020 Sep 1;21(9):1955-1960
Dr Shafai gave an excellent review of the Quaye et al article. Buprenorphine is a medication-assisted treatment for opioid use disorder. We noted that the study had a small size but MGH has found this practice to be effective. The study found evidence to support the idea that buprenorphine can be continued perioperatively and that continuation resulted in less postop pain and decreased opioid use. We noted this is contradictory to what many of us learned years ago. The limitations of the study were that pain was measured in the PACU rather than postop day one. It would have been useful to look at the pain on the second day as well.
Dr Turkiew gave a concise review of the Neuman et al article. *** Of note our very own Dr S Azim is an author on this article published in the NEJM - Congratulations! (see his "A Peek Behind the Publication" article in the November 2021 issue of SleepTalker). This pragmatic randomized superiority trial evaluated spinal anesthesia compared with general anesthesia in previously ambulatory patients older than 50 for hip rx surgery. This study found that spinal was not superior to general anesthesia for recovery of ambulating at 60 days. Delirium was similar in both types of anesthesia. It was noted that spinal use for hip fracture surgery increased 50% from 2007 to 2017. In our discussion, we had a sneak peak discussion of an article coming out in JAMA providing evidence that PACU pain med use was greater in spinal patients vs those who had general anesthesia. We discussed that in the end, we need to do what is best for patients based on their preference. A limitation of the Neuman study is that it didn’t take into account pain scores and blocks. There was also discussion on why mortality for these patients is high. This may be due to the fact that they have suffered a loss of mobility and independence.
03-22-22 Kids: APRICOTs and PRAEs
Drs. Simms, Mays, Epstein, Boorin
6:00 PM @ HSC Level 2 Lecture Hall 1
• Veyckemans. Tracheal extubation in children: Planning, technique, and complications. Paediatr Anaesth. 2020 Mar;30(3):331-338
• Marjanovic et al. Perioperative respiratory adverse events during ambulatory anesthesia in obese children. Ir J Med Sci. 2021 Jun 5.
Dr . Simms gave a concise review of the Marjanovic et al article. We discussed how thorough preoperative assessment of risk factors is mandatory. Minimization of respiratory depression can be achieved with good preoxygenation of obese children, dose optimization of meds anesthetics, analgesics combined with nonopioid analgesics, and regional anesthesia. During the discussion, it was noted that it’s good to realize which country research is done in as there may be cultural differences. Children can act differently and also have different personalities. Interestingly, different climate conditions may affect the need to prep the nose. We therefore must always critically read the literature.
Dr. Mays gave an excellent review of the Marjanovic et al article. This study emphasized that tracheal extubation should be carefully planned. Physiology-based principles should be taken into account so that the upper airway is patent and lung recruitment avoided. The pharmacology of all anesthetic agents should be considered. In addition, simulation of management of complications can be done, but basic techniques are best taught at the bedside and in the OR. During the discussion, we noted that the oral premed can have long-lasting effect. Tissues collapse, so midaz is optimal. Special-needs patients were discussed. The challenges include no iv and difficulty in ventilation. We discussed some tips such as cutting the ETT, deep extubation in the lateral position, and the use of remi at the end of a case.
05-17-21 Ventilation Support and Atelectasis
Drs. Cervo and Zabirowicz
6:00 PM @ HSC Level 2 Lecture Hall 1
• Jeong et al. Pressure Support versus Spontaneous Ventilation during Anesthetic Emergence—Effect on Postoperative Atelectasis: A Randomized Controlled Trial. Anesthesiology. 2021 Dec 1;135(6):1004-1014
Dr. Cervo gave an excellent concise review on the Jeong et al paper. The study compares pressure support ventilation to spontaneous ventilation with intermittent manual assistance during anesthetic emergence. Lung ultrasound was used for an outcome of atelectasis in the PACU. It was found that postoperative atelectasis was lower in patients undergoing lap collecting or robot assisted prostatectomy who recorded pressure support ventilation during emergence vs those who received intermittent manual assistance. It was discussed that this study is easily reproducible and understandable compared to many other clinical studies we read about. The well written aspect of it and well thought out protocol contributes to its usefulness for us. It was suggested that future studies include the high risk patients which were not included in this study.
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